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Neonatal Jaundice

Neonatal Jaundice. Dezhi Mu MD/PhD Department of Pediatrics, West China Second University Hospital, Sichuan University. Introduction. Jaundice is quite common (5mg/dl). Full term infants: at least 50% Preterm infants: over 80% Elevated blood bilirubin levels: 97%.

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Neonatal Jaundice

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  1. Neonatal Jaundice Dezhi Mu MD/PhD Department of Pediatrics, West China Second University Hospital, Sichuan University

  2. Introduction • Jaundice is quite common (5mg/dl). • Full term infants: at least 50% • Preterm infants: over 80% • Elevated blood bilirubin levels: 97%

  3. Introduction continued • When? in the first week of life • Where? skin , mucosa and white of eye • How many? blood bilirubin concentrations is ≥5-7mg/dl.

  4. Introduction continued

  5. Why Jaundice occurred? • Producing • Excreting

  6. Bilirubin Metabolism: 1. RBC: Heme bilirubin (UCB) 2. Blood: carried by bound to albumin 3. Liver: uptaken : Y protein, Z protein conjugated: UDPGT excreted： to the biliary system 4. Intestine: stercobilins -glucuronidase enterohepatic circulation

  7. The metabolic characteristics of bilirubin in newborns: 1. Bilirubin production 8.8mg/Kg/d in newborns 3.8mg/Kg/d in adults 2. Bilirubin-albumin complex formation a. preterm infant; b. acidosis

  8. The metabolic characteristics of bilirubin continued 3. Bilirubin metabolism of hepatocyte a. Hepatic uptake of bilirubin b. Bilirubin conjugation: UDPGT (uridine diphosphate glucoronyl transferase) c. Defective bilirubin excretion ability to bile system 4. Enterohepatic circulation

  9. Bilirubin toxicity 1. Conjugated bilirubin water-soluble 2. Unconjugated bilirubin lipid-soluble bilirubin-encephalopathy （kernicterus）

  10. Clinical Manifestations • Jaundice appears When: at any time during the neonatal period Where: from face chest abdomen feet

  11. Manifestations continue Evaluation of jaundice : 1. By eyes: face, 5mg/dl ( 85μmol/L ); abdomen, 10-15mg/dl; feet, 15-20mg/dl ; 2. By transcutaneous measurement : used for screening 3. By serum levels : standard

  12. Manifestations continue Classification: • Physiological Jaundice • Pathological Jaundice

  13. Manifestations continue • Physiological jaundice :1. General state is well 2. Appears 2-3days (>24h of age) peaks < 12.9mg/dl (full term infants) <15mg/dl (preterm infants) fades <2 week (term infants) <4 weeks (preterm infants) 3. Accumulates <5mg/dl/d 4. Direct bilirubin <2mg/dl

  14. Manifestations continue • Pathological Jaundice 1. Appears earlier (first 24 hours of life) 2. Peaks >12.9mg/dl (full term infants) >15mg/dl (preterm infants) Fades >2 weeks (term infants) >4 weeks (preterm infants) 3. Accumulates >5mg/dl/d 4. Direct bilirubin >2mg/dl 5.Jaundice recurrent

  15. Common causes of pathological jaundice 1. Unconjugated bilirubinemia: a. hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice

  16. Causes of pathological jaundice continue 2. Conjugated bilirubinemia: a. Neonatal hepatitis b. Biliary obstruction (cholestatic jaundice) biliary atresia, common bile duct stenosis c. Congenital metabolic diseases α-1 antitrypsin deficiency

  17. Hemolytic disease of newborn Hemolytic disease: ABO: 85.3% Rh : 14.6% MN : 0.1%

  18. Hemolytic disease of newborncontinued ABO incompatibility the mother: type O the infant: type A or B Rh incompatibility the mother： Rh（-） the infant: Rh（+）D,E,C,d,e,c

  19. Pathogenesis

  20. Pathophysiology Red blood cell breakdown Hyperbilirubinemia Anemia Jaundice • Liver • Spleen • Heart, other organs • Hydrops Kernicterus Seizures etc.

  21. Clinical Manifestations: ABO Rh 1.Jaundice : mild severe 1-2 day 24 h 2.Anemia:mild severe (3-6 weeks) heart failure 3.Hepato- rare common splenomegaly

  22. Complication Kernicterus: Phase 1: decreased alertness Hypotonia Poor feeding Phase 2: Hypertonia, Retrocollis, opisthotonus Phase 3: Hypotonia

  23. Laboratory tests: 1. Blood type incompatibility 2. Hyperbilirubinemia : Unconjugated bilirubin level 3. Hemolytic tests 1). Hemoglobin level : low 2). Reticulocytes:10–15% 3). Nucleated RBC

  24. Laboratory tests continued Antibody test 1). Direct Coombs test (+) confirm 2). Antibody release test (+) confirm 3). Free antibody test (+) judge

  25. Treatments 1). Phototherapy 2). Exchange transfusion 3). Internal Medicine

  26. Treatments continued • During pregnancy 1. Intrauterine blood transfusion 2. Early delivery

  27. Treatments continued • After birth 1. Phototherapy Principle : photon of light Three photochemical reactions: 1). Structure isomer 2). Geometric isomer 3). Photo-oxidation Photoproducts excretion: w/o conjugation

  28. Treatments continued Indications of phototherapy : Unconjugated bilirubinemia Bilirubin level >12mg/dl Light source: Spectral outputs 420 to 500nm

  29. Treatments continued Side effects of phototherapy : a. diarrhea b. fever c. skin rash d. bronze baby syndrome (conjugated bilirubin>4mg/dl)

  30. Treatments continued 2. Exchange Transfusions: a. Severe hemolytic disease b. Refractory to phototherapy

  31. Treatments continued Aims of transfusions: a. Remove antibodies b. Remove bilirubin c. Correct anemia

  32. Treatments continued Indication of transfusions: one of the follows • 20mg/dl (340 μmol/L) • >4mg/dl,Hgb<120g/L, edema • 0.7mg/dl/h • Kernicterus

  33. Treatments exchange transfusions Source of the blood mother newborns For Rh: Rh ABO incompatibility For ABO: “AB” plasma “O” cells incompatibility packed RBC

  34. Treatments exchange transfusions Potential complications: a. Infection b. Necrotizing enterocolitis NEC c. Thromboembolic complications

  35. Treatments continued 3. Pharmacological agents: a. Phenobarbital Effects: Uptake, Conjugation Excretion b. Albumin c. IVIG

  36. Preventions For ABO incompatibility: No For Rh incompatibility 300 μg of human anti-D globulin within 72 h of delivery.

  37. 1.Unconjugated bilirubinemia: a. Hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice

  38. 1.Unconjugated bilirubinemia: b. G-6-PD deficiency; male, jaundice, enzyme activity c. Breast milk jaundice causes: unclear, -glucuronidase follows physiologic jaundice: 4-7 d breast feeding persist for several weeks.

  39. Conjugated bilirubinemia: 2.Conjugated bilirubinemia: a. neonatal hepatitis b. biliary obstruction (cholestatic jaundice) biliary atresia, common bile duct stenosis c. congenital metabolic diseases α-1 antitrypsin deficiency

  40. Case analysis : 24 old male infant, gravida1,para 1. Apgar scores: 8 at 1 min Mother: blood type “O” PE: icterus appeared on face and trunk skin liver edge 1cm palpable spleen tip

  41. Case analysis continued Lab tests: Hgb:13g/dl, reticulocyte count : 7% Blood smear: nucleated RBC Blood type: A, Rh-positive Serum bilirubin: 12.9mg/ml Direct Coomb’s test: weakly positive Question: what’s the risk factor ?

  42. Department of Pediatrics Thank you! Questions？

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